Course2nd ECG normal and Trop T < 3 at 6 hours post onset of pain2nd litre of saline running, BP still 90/60mm/Hg, HR 60/min, with normal peripheral perfusionBP both arms the sameChest pain “2/10”Decision to order CT angiogram of chest
Intimal tear / flap ofdissection in aortic arch
7.10AM Patient transferred to the OT for repair of the type A dissection and the aneurysmal dilatation of aortic root.
Relatively uncommon (2.6-3.3/100 000 person- years)Initial event in aortic dissection is a tear in the aortic intima.Propagation of the dissection may be 1. Proximal (retrograde) 2. Distal (antegrade)
Complications Aortic valve injury with regurgitation Pericaridal tamponade End organ ischemia, examples include syncope, CVA, mesenteric or renal ischaemia.
Risk factors for aortic dissectionAdvancing ageMale sex 2:1 (Female – pregnancy)Systemic hypertensionPre-existing aortic aneurysmAtherosclerosis
Risk factors for under age 40Collagen vascular disordersVasculitisBicuspid aortic valveAortic coarctationTurners syndromeMarfan syndromePrior aortic valve surgeryInstrumentationTraumaHigh intensity weight lifting or other exerciseCocaine
ClassificationStanfordType A –ascending AortaType B – all other types / sites in aortaDeBakeyType I – Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally.Type II – Originates / confined to the ascending aorta.Type III – Originates in descending aorta, rarely extends proximally but will extend distally.
DiagnosisRoutine bloods – non diagnostic D-dimer < 500ng/ml unlikely to be dissectionHistory Anterior chest pain in ascending aortic dissection Severe sharp or tearing posterior chest or back pain when the dissection progresses distal to the subclavian artery
Pain can associated withSyncopeStrokeMIHeart failureEnd organ ischemia (splanchnic, renal, extremity or spinal cord ischaemia)Hypertension common with type BHypotension
Diagnosis of aortic dissection dependsupon demonstration of the dissection onimaging studies CXR CT MRI TEE / TTE